Unequal spending, unequal care: Race and ethnicity and their interactions with clinical and socioeconomic factors in health care expenditures among older adults with cardiovascular disease

BACKGROUND: Cardiovascular disease (CVD) accounts for the highest health care expenditures in the United States, with persistent disparities among racial and ethnic minorities. OBJECTIVE: To evaluate factors contributing to differences in total health care expenditure among Hispanic, non-Hispanic Black (hereafter Black), and non-Hispanic White (hereafter White) adults aged 65 years and older with CVD. METHODS: This study had a repeated cross-sectional design and used data from the Medical Expenditure Panel Survey (2014-2021). The primary outcome was the total health care direct expenditure (inpatient, outpatient, and medical and pharmacy cost). Inclusion criteria were being aged at least 65 years and having at least 1 lifetime diagnosis of CVD. Survey-weighted descriptive analyses were conducted, followed by 3 hierarchical log-linear regression models. Model 1 included race and ethnicity only. Model 2 adjusted for clinical factors (sex, age at first CVD diagnosis, CVD severity, and Elixhauser comorbidity score). Model 3 additionally incorporated socioeconomic, functional, and contextual factors, including education, income, insurance status, physical and cognitive limitations, geographic region, and survey year. RESULTS: The final sample included 8,585 participants (weighted N = 11,412,569). In the unadjusted model, Hispanic and Black participants had 9% ( P = 0.03) and 11% ( P = 0.005) lower health care expenditures, respectively, compared with White participants. After adjustment for clinical factors, Hispanic participants had 26% lower expenditures ( P < 0.001), and the Black-White difference was no longer statistically significant. In the fully adjusted model, race and ethnicity were not independently associated with expenditure; however, significant interactions were identified between race and ethnicity and sex (Hispanic women: +32%, P = 0.002), physical limitations (Hispanic: +131%, P = 0.005; Black: +118%, P = 0.04), cognitive limitations (Black: +129%, P = 0.008), and geographic region, alongside independent associations with education, income, insurance status, and physical and cognitive limitations. CONCLUSIONS: Differences in health care expenditure among older adults with CVD appear to be shaped by a combination of clinical, socioeconomic, and contextual factors rather than race and ethnicity alone. These findings highlight the importance of equity-focused, value-based strategies that address underlying social determinants of health to improve access, reduce disparities in health care utilization, and potentially lower overall health care costs. Importantly, lower expenditures may reflect underutilization of necessary care rather than improved efficiency.